Published by Ounce of Prevention Fund. Toward the ABCs. Building a Healthy Social and Emotional Foundation for Learning and Living

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1 Published by Ounce of Prevention Fund Toward the ABCs Building a Healthy Social and Emotional Foundation for Learning and Living

2 Building a Healthy Social and Emotional Foundation for Learning and Living Melissa is twelve months old. She and her mother, Julie, have just arrived at the pediatrician s office for a well-child visit. They are greeted in the waiting room by the nurse who gives Julie a questionnaire to fill out. Melissa sits limply on her mother s lap as they wait to see the doctor. During the exam the pediatrician is struck by Melissa s apathy to her surroundings; this is not the same baby bursting with energy and curiosity whom he had seen a few months earlier. Outside the examining room, he shares his observation with the nurse who then enters the room. Using her clinical skills as well as Julie s response to the questionnaire, the nurse is able to engage Julie in dialogue. She quickly learns that Julie s husband, Mike, was recently involved in a serious accident. After spending over a month in the hospital, he is now home on disability and Julie has had to go back to work full-time to help pay the bills. A neighbor now cares for Melissa in the mornings; Melissa s grandmother picks her up at noon and stays with her until Julie gets home from work. Julie mentions to the nurse that Melissa no longer sleeps through the night, cries more frequently, and has become difficult to soothe. With all the adjustments the family has had to make as a result of her husband s disability, Julie and Mike s nerves are constantly on edge and they have little energy and tolerance to deal with Melissa s difficult behavior. Julie and the nurse spend some time discussing how the family s circumstancemight be affecting Melissa. At the recommendation of the nurse, Julie hesitantly agrees to a referral to the parent-infant program at the local health department where a full assessment of Melissa s behavior and her relationship with her parents is completed by an early childhood mental health specialist. At the next well-child visit in the pediatrician s office, Julie informs the nurse that the specialist has been working with her and Mike to better understand Melissa s behavior. More importantly, the specialist is helping them identify strategies that respond to their concerns regarding Melissa s behavior but don t undermine their parenting capacity and beliefs. Why is Healthy Social and Emotional Development so Important? While it may be surprising to realize that a child as young as Melissa might be experiencing significant distress, the truth is that emotional and behavioral concerns do arise in very young children and may affect their ability to succeed in school and on the playground. The good news is that with proper nurturing and support, Melissa can regain her curiosity and playfulness. However, too often in today s world, families are not as fortunate as Melissa and her parents. Most individuals working with young children and their families do not have the knowledge and skills to identify early warning signs, and communities lack the resources and trained professionals to address social and emotional concerns early on. When these concerns go undetected and are not addressed early, they may interfere with a child s ability to think clearly, learn new skills, and form positive relationships. All young children, regardless of race, socioeconomic status or risk, need to develop a foundation for learning and living more basic than knowledge of the ABCs. In fact, to be prepared for school as well as the normal challenges associated with everyday situations and interactions, how young children feel and behave is just as important as what they know and think. When a child arrives for his first day of kindergarten, he will be expected to cooperate and follow directions, be able to work independently, know when and how to ask for help, and be able to get along with his classmates and teacher. A child who is able to manage a wide range of feelings and has developed appropriate coping mechanisms will be available to focus his attention on learning and exploration. In contrast, a child who is overwhelmed with fears and anxieties and has difficulty regulating his emotions may struggle with reading, writing, and arithmetic. 1

3 Research suggests that between one-quarter and one-third of young children are perceived as not being ready to succeed in school. 1 For a significant number of these children, concerns center around emotional and behavioral difficulties that prevent them from making the cognitive gains they need when they enter school. Not surprisingly, many of them end up in the special education system. During the school year, 6% of children between the ages of six and eleven receiving special education services had a primary diagnosis of emotional disturbance (ranking fourth among all possible diagnoses). 2 Emotional disturbances are also frequently linked to speech and language impairments and learning disabilities. The emerging field of early childhood mental health seeks to address these issues and promote the social and emotional well-being of children under the age of five through their relationships with caregivers. In addition to parents, caregivers include child care providers, home visitors, foster parents, and other individuals who nurture and care for young children. Early childhood mental health services encompass a variety of strategies, ranging from promoting and maintaining social and emotional competencies and skills to working with parents and other caregivers around such problems as sleeping and eating difficulties to addressing disturbances in the parent-child relationship. These strategies are not to be provided in isolation, but rather need to be considered within the family and cultural context and infused into the existing programs serving young children and their families in the community. The Brain Connection Current understanding of the human brain has revealed a connection between psychological distress and brain development. While experiences shape and influence brain activity throughout the life span, children will undergo the most rapid brain development in the first few years of life. During this period when the child s brain is becoming hard-wired, he is particularly receptive to positive interactions and experiences, but also vulnerable to negative ones. At the moment, we know the most about how traumatic experiences affect the brains of children who develop Post-Traumatic Stress Disorder (PTSD). Similar to adults with PTSD, these children have trouble sleeping, cannot control their memories of the trauma, and seem to be on constant alert. Using the most up-to-date method, researchers at the Developmental Traumatology Laboratory at Western Psychiatric Institute and Clinics in Pittsburgh are studying the stress circuits and brain development of traumatized children. Through brain scans of maltreated children with PTSD, the Pittsburgh group found striking evidence that the brain volume of these children is smaller, leading to concerns that these children may suffer from long-term cognitive and emotional difficulties. 3 This and other research currently underway are beginning to confirm what many professionals in the field of early childhood have long suspected that a child s earliest relationships and experiences play an important role in shaping the brain. (For more information on the brain, see Starting Smart, a publication of the Ounce of Prevention Fund, or visit Brain Wonders at 2

4 What Puts Young Children at Risk for Emotional or Behavioral Difficulties? A child s social and emotional development results from the interplay between nature and nurture the characteristics a child brings with her into the world and the way the world treats her. The opportunity and responsibility to foster good mental health in early childhood is particularly significant considering the complex world into which children are born today. The majority of young children have parents who are balancing the competing demands of work and family, often leaving them with less time and energy to tend to their children s emotional needs. Many children have parents who are divorced or are being raised by single parents, others have parents dealing with mental health issues of their own, and far too many children are exposed to violence. Research has demonstrated that certain environmental conditions and experiences put young children at risk of developing emotional or behavioral difficulties; these risk factors include low birth weight or serious medical conditions, exposure to high levels of lead, developmental delays or disabilities, parental substance abuse or mental illness, and harsh or inappropriate parenting. The risk rises when children are exposed to a number of these factors simultaneously. For example, poverty alone may not be detrimental to a particular young child s development, but if she is also exposed to domestic violence and lacks a consistent primary caregiver, the likelihood of her experiencing distress and problem behavior is much greater. One of the few U.S. studies to examine the effects of environmental factors over time on the development of children from birth through adolescence the Rochester Longitudinal Study found that by age four, children in the high-risk group were twelve times more likely than the low-risk children to be rated as having clinical mental health symptoms. 4 These differences in child well-being continued through adolescence, reinforcing the need to intervene early with children and families exposed to multiple risk factors. Which Behaviors may Indicate a Problem? All young children and parents struggle when faced with new and sometimes challenging tasks or situations. When the tasks or situations are consistently too difficult or too overwhelming, or the caregiver s help is insufficient, we see behaviors that signal a child s distress. Although special expertise is needed to conduct a comprehensive social and emotional evaluation, there are certain behaviors a child may exhibit that can help identify those children and families who may benefit from a full evaluation. To warrant concern, the behavior should occur more often and last longer when compared to other children of the same age. Infants and toddlers (birth to 3 years old) Feeding or sleeping difficulties Frequently bites or hits others with no provocation Anxious and clingy attachment to caregiver No stranger anxiety; indiscriminate attachment Sad facial expression; avoids eye contact Uncomfortable when held Too easily upset and difficult to soothe Preschoolers (3 to 5 years old) Engages in compulsive activities (e.g., head banging) Throws wild, despairing tantrums Withdrawn; shows little interest in social interaction Displays repeated aggressive or impulsive behavior Difficulty playing with others Little or no communication; lack of language Loss of earlier developmental achievements Source: Adapted from Infusing infant mental health practices into front-line caregiving, Infants and Young Children, Vol. 14 (1),

5 The Effects of Maternal Depression on the Developing Child Social and emotional development in the first few years of life is strongly correlated with the quality of the relationship between a child and her primary caregiver, most often the mother. Not surprisingly, the mother s own emotional stability may compromise her ability to nurture the child. An estimated 1 in 10 mothers with young children suffers from depression, with prevalence rates often reaching two times this level among mothers living in poverty. 6 While some mothers who experience depression are able to provide consistent and sensitive care, many struggle to be emotionally responsive to their children and may have difficulty helping them learn how to behave appropriately. A National Institute of Child Health and Human Development study found that, at thirty-six months of age, children of depressed mothers: (1) performed more poorly on measures of school readiness, verbal comprehension, and expressive language skills, and (2) were reported to be less cooperative and to exhibit more problem behavior when compared to children of mothers who had never reported depression. 7 While a positive relationship with a father or other loving caregiver can help counter the negative impact that maternal depression may have on a child s development, early identification and access to treatment for maternal depression are critical for the mother and child. What Kind of Support can Help? Early childhood mental health strategies are relationship-based and seek to strengthen the way parents and other caregivers relate to young children within the family and cultural context. Strategies also address the specific social and emotional needs of children under the age of five and help cultivate safe and nurturing environments in which young children can thrive. They are designed to be infused into the existing array of early childhood programs and services including health care, child welfare, home visiting, and early care and education. Early childhood mental health strategies vary in intensity and purpose and fall along a continuum ranging from promotion to prevention to targeted intervention. 8 Level I Promotion Through nurturing and responsive caregiving, young children embark on a healthy social and emotional trajectory that prepares them for school and life success. Even the most attentive caregivers can benefit from support that helps them be more attuned to their children s emotional cues and appropriately respond to their specific needs. If properly trained, front-line workers (e.g., pediatricians, public health nurses, child care providers) can implement a range of strategies that promote the social and emotional well-being of all young children including: Being aware and supportive of the mother s emotional needs during pregnancy and preparing parents for the psychological adjustments of parenthood Helping parents and caregivers better understand the normal range of social and emotional development in children under five Building parents confidence and satisfaction in their relationships with their children Identifying flexible approaches to supporting a child s ongoing social and emotional development within the context of family, community and cultural expectations Providing strategies to parents for understanding and negotiating conflict with a young child and promoting pro-social behavior Screening children under five for social and emotional concerns as part of a global developmental assessment and referring for further evaluation as needed 4

6 Assessing Young Children s Social and Emotional Development Screening children periodically for emotional and behavioral concerns should be an integral component of any developmental assessment. Screenings are an opportunity to provide education and anticipatory guidance to parents learning to understand and respond to their child s emotional cues. Screenings also help to identify children who may be exhibiting problem behavior. New screening tools, such as the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE), have been developed to assess the social and emotional development of children under five. Children who screen positive for an emotional or behavioral concern should be referred for a comprehensive evaluation. While there is still a dearth of programs and clinicians equipped to evaluate the mental health status of very young children, individuals conducting screenings must do their best to identify the most appropriate places in the community for referrals which may include a local health department, a mental health agency, the Early Intervention system for children under three, or the special education system for children between the ages of three and five. Level II Prevention The social and emotional development of some young children, including those who face constitutional and/or environmental risks may be compromised if they are not adequately supported. In addition to promotion strategies, their caregivers may need more individualized support to help these children develop appropriate social and emotional competencies. With proper training, professionals who have an ongoing relationship with these families (e.g., early interventionists, home visitors, social workers) are well-positioned to implement the following strategies: Making recommendations for developmentally appropriate ways to interact with the child Helping caregivers recognize the unique strengths of the child and the family and identifying ways to build on these strengths to promote resilience Identifying emotional and behavioral concerns as well as challenges in the parent-child relationship, and providing recommendations to enhance responsive caregiving Using videotaped interactions between the parent and child to reinforce nurturing caregiving and guide understanding of the child s cues and behaviors Assessing environmental risk factors and making referrals as needed Parenting education and parent support groups Case consultation with an early childhood mental health specialist Connecting the family with diagnostic and intervention services as needed 5

7 Level III Targeted Intervention The growing body of research on early childhood and brain development has led to increased recognition that infants, toddlers and preschool children are susceptible to many of the same psychological conditions that have long been acknowledged in older children and adults such as depression and anxiety although they are uniquely expressed in the young child. 9 Early childhood mental health targeted interventions are intended for families in which there is a disturbance in the parent-child relationship or for children whose emotional development may deviate significantly from typical behavior. In addition to promotion and prevention strategies, targeted interventions used by individuals with specialized training in early childhood mental health include: Assessing the nature of a particular disturbance within the family and cultural context Providing specific techniques for addressing the child s behavioral symptoms Videotaping interactions between the parent and child to help the parent become more aware of his or her positive and negative interactions with the child Helping parents explore and understand the impact of their own childhood memories on interactions with their children Coaching parents about developmentally appropriate ways to interact with the child both verbally and non-verbally Play, art and music therapy for preschool children Assisting parents in obtaining additional needed support and services (e.g., treatment for depression, mental illness, substance abuse) Who Can Help? Early childhood mental health specialists consult with staff in early childhood programs to help them better understand and incorporate Level I and Level II mental health strategies into their work. Specialists with clinical training can also provide the full range of Level III targeted intervention strategies to young children and their families. These specialists come from a variety of disciplines including psychiatry, psychology, social work, child development, and nursing. The role of the early childhood mental health specialist varies depending on the scope of the program and the specific needs and interests of staff and families. They are usually called upon to provide services such as child observations, social and emotional assessments, behavior management training, crisis intervention, parent education and support, and play therapy. Many early childhood programs are struggling to adapt to the increasing number of children exhibiting emotional and behavioral difficulties. In a recent Illinois survey of early childhood programs, 70% of the programs surveyed reported that they do not feel adequately prepared to meet the social and emotional needs of the children and families they serve. Furthermore, 42% of child care programs have asked a family to withdraw a child because the staff were unable to manage the child s behavior. When asked what would better prepare the program to meet these needs,programs most often requested the availability of additional staff or consultants who have expertise in early childhood mental health. 10 6

8 At a Glance Early Childhood Mental Health in Practice At the DuPage County Health Department in suburban Chicago, early childhood mental health specialists have been providing clinical intervention to children under five and their parents for ten years. Parents receiving mental health services through the health department are referred to an early childhood mental health specialist as appropriate. The specialist supports the parent and young child as they play and interact with each other, and helps the parent reflect on the meaning of her interactions with the child. Through this therapeutic relationship, the parent is able to increase her understanding and enjoyment for the child; in turn the child is able to develop a healthier, more secure attachment to the parent. The early childhood mental health specialist also provides short-term and long-term consultation to child care providers in DuPage County to help increase their responsiveness to the social and emotional needs of the children in their care and sensitivity to the mental health concerns of their families. Child care providers often call on the specialist when they observe an emotional or behavioral concern in a particular child such as inappropriate hitting or biting, extreme separation anxiety, or soiling by a child who was previously toilet-trained. The specialist observes the child in the child care setting, and perhaps even the home, to put the behavior into perspective and help the provider and parent better understand the underlying meaning of the behavior. Part of the specialist s role is to validate the concerns of both parent and provider and help them agree upon intervention strategies. The early childhood mental health program at the DuPage County Health Department is financed through a combination of county funds, Medicaid, and family fees (based on a sliding scale). Mental health in early childhood is defined by the U.S. Surgeon General as the achievement of expected cognitive, social, and emotional milestones, as well as the development of secure attachments, satisfying social relationships, and effective coping skills. As highlighted in the Surgeon General s Report on Mental Health, children and families are suffering because of missed opportunities for prevention and early identification, fragmented services, and lack of resources. A Call to Action The social and emotional well-being of our youngest children must be moved to the forefront of public policy and financing discussions. If we are committed to ensuring that children are better prepared to learn in school and go on to lead successful and fulfilling lives, then states must engage in serious, coordinated discussions to plan and implement early childhood mental health strategies that respond to the unique and varied needs of children under five and support their families and other caregivers. Currently, no one agency or system is equipped to address this issue, nor should we ever expect the responsibility to fall on a single entity. Building a systemic approach to providing early childhood mental health strategies will require innovative collaborations and approaches around service delivery, training and workforce development, funding, and policy. 7

9 State agencies, policymakers, early childhood professionals, advocates, and families must make the social and emotional well-being of our youngest children a top priority and work together to: Develop a strategic plan for integrating early childhood mental health strategies into the existing array of programs and services Develop a public education campaign that raises awareness about the importance of supporting the social and emotional well-being of young children and the unique mental health needs of this population Develop clear policies and program goals related to early childhood mental health in programs and services that touch the lives of young children including early care and education, health care, child welfare, Early Intervention, special education, family support, home visiting, TANF, mental health, and substance abuse Strengthen collaboration among publiclyfunded programs and services and develop blended funding streams to pay for early childhood mental health training and consultation Systematically screen children under five for social and emotional concerns when conducting developmental assessments Improve the capacity of the special education and Early Intervention systems (Parts B and C of the Individuals with Disabilities Education Act) to address the needs of children with emotional and behavioral difficulties Create mechanisms to cover early childhood mental health intervention services through Medicaid, SCHIP and private insurance Develop the specialized capacity needed within the existing mental health system to serve children under five and support parents with mental illness in their parenting role, and make these children and families a priority Selected Resources Building Services and Systems to Support the Healthy Emotional Development of Young Children: An Action Guide for Policy Makers (2001) By Jane Knitzer Available through the National Center for Children in Poverty (212) or Early Childhood Mental Health Consultation (2000) By Elena Cohen and Roxanne Kaufmann Available through the National Technical Assistance Center for Children s Mental Health Georgetown University Child Development Center (202) or Funding Early Childhood Mental Health Services and Supports (2001) By Amy Wishmann, Donald Kates, and Roxanne Kaufmann Available through Georgetown University Child Development Center Center for Child Health and Mental Health Policy (202) or research/gucdc/fundingpub.html Heart Start: The Emotional Foundations of School Readiness (1992) By ZERO TO THREE: National Center for Infants, Toddlers and Families Available through ZERO TO THREE (800) or Off to a Good Start: Research on the Risk Factors for Early School Problems and Selected Federal Policies Affecting Children s Social and Emotional Development and Their Readiness for School (2000) By Doreen Cavanaugh, Lynne Huffman, Amy Kerivan, John Lippitt, Sarah Mehlinger, and Otrude Moyo Commissioned by FAN, The Child Mental Health Foundations and Agencies Network (301) or childhp/goodstart.cfm U.S. Surgeon General s Report on Mental Health (1999) Available through the U.S. Surgeon General s Office (202) or 8

10 Acknowledgements We wish to thank the following organizations for their contributions in the development of this publication: DuPage County Health Department, Early Head Start National Resource Center, Erikson Institute, Illinois Association for Infant Mental Health, Illinois Birth to Five PAC, National Center for Children in Poverty, University of Illinois at Chicago-Department of Disability and Human Development, University of Minnesota - Department of Social Work, University of Nebraska at Lincoln-Department of Family and Consumer Sciences, University of Nebraska at Omaha- Department of Psychology, Washburn Child Guidance Clinic (Minneapolis), Voices for Illinois Children, Yale University School of Medicine - Child Study Center, and ZERO TO THREE: National Center for Infants, Toddlers and Families. Author: Paula Casas Design: Silvio Design, Inc Printing: IPP Lithocolor Notes 1 Knitzer, J. (2001). Using Mental Health Strategies to Move the Early Childhood Agenda and Promote School Readiness. New York: Carnegie Corporation of New York & National Center for Children in Poverty. 2 U.S. Department of Education, Office of Special Education Program, Data Analysis System (2000). Posted at data.org. 3 Hawley, T. (2000). Starting Smart: How Early Experiences Affect Brain Development. Chicago: Ounce of Prevention Fund. 4 Sameroff, A. & Fiese, B. (2000). Models of development and developmental risk. In Zeanah, C. (Ed.) Handbook of Infant Mental Health, Second Edition. New York: Guilford Press (chapter 1, pp. 3-19). 5 Graham, M., White, B., Clarke, C. & Adams, S. (2001). Infusing infant mental health practices into front-line caregiving. Infants and Young Children, Vol. 14 (1), Shonkoff, J. & Phillips, D. (Eds.) and National Research Council (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development (chapter 9, pp ). Washington, DC: National Academy Press. 7 National Institute of Child Health and Human Development (1999). Maternal Depression Linked with Social and Language Development, School Readiness: Maternal Sensitivity Helps These Children Fare Better. Posted at newreleases/ depression.htm. 8 For a comparable framework see Florida State University Center for Prevention and Early Intervention Policy (2001). Florida s Strategic Plan for Infant Mental Health: Establishing a System of Mental Health Services for Young Children and their Families in Florida. Tallahassee, FL: Author. Report prepared for Florida Developmental Disabilities Council. 9 Shonkoff, J. & Phillips, D. (Eds.) and National Research Council (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development (chapter 5, pp ). Washington, DC: National Academy Press. 10 Cutler, A. & Gilkerson, L. (2001). Illinois infant mental health survey: findings and recommendations. The Unmet Needs Project Final Report. Chicago: University of Illinois at Chicago and Erikson Institute. 9

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